Preeclampsia Onset, Days to Delivery, and Autism Spectrum Disorders in Offspring: Clinical Birth Cohort Study.

BACKGROUND: Maternal preeclampsia is associated with a risk of autism spectrum disorders (ASD) in offspring. However, it is unknown whether the increased ASD risk associated with preeclampsia is due to preeclampsia onset or clinical management of preeclampsia after onset, as clinical expectant management of preeclampsia allows pregnant women with this complication to remain pregnant for potentially weeks depending on the onset and severity. Identifying the risk associated with preeclampsia onset and exposure provides evidence to support the care of high-risk pregnancies and reduce adverse effects on offspring. OBJECTIVE: This study aimed to fill the knowledge gap by assessing the ASD risk in children associated with the gestational age of preeclampsia onset and the number of days from preeclampsia onset to delivery. METHODS: This retrospective population-based clinical cohort study included 364,588 mother-child pairs of singleton births between 2001 and 2014 in a large integrated health care system in Southern California. Maternal social demographic and pregnancy health data, as well as ASD diagnosis in children by the age of 5 years, were extracted from electronic medical records. Cox regression models were used to assess hazard ratios (HRs) of ASD risk in children associated with gestational age of the first occurrence of preeclampsia and the number of days from first occurrence to delivery. RESULTS: Preeclampsia occurred in 16,205 (4.4%) out of 364,588 pregnancies; among the 16,205 pregnancies, 2727 (16.8%) first occurred at <34 weeks gestation, 4466 (27.6%) first occurred between 34 and 37 weeks, and 9012 (55.6%) first occurred at ≥37 weeks. Median days from preeclampsia onset to delivery were 4 (IQR 2,16) days, 1 (IQR 1,3) day, and 1 (IQR 0,1) day for those first occurring at <34, 34-37, and ≥37 weeks, respectively. Early preeclampsia onset was associated with greater ASD risk (P=.003); HRs were 1.62 (95% CI 1.33-1.98), 1.43 (95% CI 1.20-1.69), and 1.23 (95% CI 1.08-1.41), respectively, for onset at <34, 34-37, and ≥37 weeks, relative to the unexposed group. Within the preeclampsia group, the number of days from preeclampsia onset to delivery was not associated with ASD risk in children; the HR was 0.995 (95% CI 0.986-1.004) after adjusting for gestational age of preeclampsia onset. CONCLUSIONS: Preeclampsia during pregnancy was associated with ASD risk in children, and the risk was greater with earlier onset. However, the number of days from first preeclampsia onset to delivery was not associated with ASD risk in children. Our study suggests that ASD risk in children associated with preeclampsia is not increased by expectant management of preeclampsia in standard clinical practice. Our results emphasize the need to identify effective approaches to preventing the onset of preeclampsia, especially during early pregnancy. Further research is needed to confirm if this finding applies across different populations and clinical settings.

Maternal obesity and diabetes during pregnancy and early autism screening score at well-child visits in standard clinical practice.

LAY ABSTRACT: Early intervention and treatment can help reduce disability in children diagnosed with autism spectrum disorder. Screening for autism spectrum disorder in young children identifies those at increased likelihood of diagnosis who may need further support. Previous research has reported that exposure to maternal obesity and diabetes during pregnancy is associated with higher likelihood of autism spectrum disorder diagnosis in children. However, little is known about whether these maternal conditions are associated with how very young children score on autism spectrum disorder screening tools. This study examined associations between exposure to maternal obesity and diabetes during pregnancy and offspring scores on the Quantitative Checklist for Autism in Toddlers, an autism spectrum disorder screening questionnaire administered between 18-24 months at well-child visits. A higher score on the Quantitative Checklist for Autism in Toddlers suggests a higher likelihood of autism spectrum disorder; children with scores 3 or greater are referred to developmental pediatricians for evaluation. Our study found that children of mothers with obesity or diabetes during pregnancy had higher scores than children whose mothers did not have these conditions. Associations with maternal obesity and gestational diabetes diagnosed at or before 26 weeks of pregnancy were also present in children who did not have later autism spectrum disorder diagnoses, suggesting that exposure to these conditions during early pregnancy may be associated with a broad range of social and behavioral abilities. Identifying associations between maternal health conditions and early Quantitative Checklist for Autism in Toddlers screening scores could influence future screening and provision of support for children of mothers with these conditions.

Association of Labor Epidural Analgesia, Oxytocin Exposure, and Risk of Autism Spectrum Disorders in Children.

Importance: Maternal labor epidural analgesia (LEA) and oxytocin use for labor and delivery have been reported to be associated with child autism spectrum disorders (ASD). However, it remains unclear whether these 2 common medications used during labor and delivery have synergistic associations with ASD risk in children. Objective: To assess the independent associations of LEA and oxytocin during labor and delivery with ASD, as well as outcome modification associated with the concurrent use of both interventions. Design, Setting, and Participants: Data for this cohort study included 205 994 singleton births with vaginal deliveries in a single integrated health care system in Southern California from calendar years 2008 to 2017. Children were followed up to December 31, 2021. Data on use of LEA and oxytocin, covariates, and ASD outcome in children were obtained from electronic medical records. Cox proportional hazards regression was used to estimate the hazard ratios (HRs) adjusting for covariates. Exposures: Labor epidural analgesia and/or oxytocin use during labor and delivery. Main Outcomes and Measures: A child's clinical diagnosis of ASD during follow-up and at age of diagnosis. Results: Among the cohort, 153 880 children (74.7%) were exposed to maternal LEA and 117 808 children (57.2%) were exposed to oxytocin during labor and delivery. The population of children was approximately half boys and half girls. The median (IQR) age of the mothers was 30.8 (26.8-34.5) years for those not exposed to LEA, 30.0 (25.9-33.8) years for those exposed to LEA, 30.4 (26.5-34.1) years for those unexposed to oxytocin, and 30.0 (25.9-33.9) years for those exposed to oxytocin during labor and delivery. A total of 5146 children (2.5%) had ASD diagnosed during follow-up. Oxytocin exposure was higher among LEA-exposed (67.7%) than -unexposed (26.1%) children. The ASD risk associated with LEA was independent of oxytocin exposure (HR, 1.28; 95% CI, 1.18-1.38); however, the ASD risk associated with oxytocin was not significant after adjusting for LEA exposure (HR, 1.05; 95% CI, 0.99-1.12). A significant interaction of LEA and oxytocin on child ASD risk was found (P = .02 for interaction). Compared with no exposure, HRs were 1.20 (95% CI, 1.09-1.32) for LEA alone, 1.30 (95% CI, 1.20-1.42) for both LEA and oxytocin, and 0.90 (95% CI, 0.78-1.04) for oxytocin alone. Conclusions and Relevance: The findings of this cohort study suggest an association between maternal LEA and ASD risk in children, and the risk appeared to be further increased if oxytocin was also administered. Oxytocin exposure without LEA exposure was not associated with ASD risk in children. These findings must be interpreted with caution. Further studies are needed to replicate or refute the study results and examine biological plausibility.

Time Out: The Impact of Physician Burnout on Patient Care Quality and Safety in Perioperative Medicine.

Perioperative care delivery is a patient-centered, multidisciplinary process. It relies heavily on synchronized teamwork from a well-coordinated team. Perioperative physicians-surgeons and anesthesiologists-face enormous challenges in surgical care delivery due to changing work environments, post-COVID consequences, shift work disorder, value conflict, escalating demands, regulatory complexity, and financial uncertainties. Physician burnout in this working environment has become increasingly prevalent. It is not only harmful to physicians' health and well-being, but it also affects the quality and safety of patient care. Additionally, the economic costs associated with physician burnout are untenable due to the high turnover rate, high recruitment expenses, and potential early permanent exit from medical practice. In this deteriorating environment of unbalanced physician supply/demand, recognizing, managing, and preventing physician burnout may help preserve the system's most valuable asset and contribute to higher quality and safety of patient care. Leaders in government agencies, health care systems, and organizations must work together to re-engineer the health care system for better physicians and patient care.

Veiled Harm: Impacts of Microaggressions on Psychological Safety and Physician Burnout.

Microaggression is widespread in the health care industry and occurs in every health care delivery setting. It comes in many forms, from subtle to obvious, unconscious to conscious, and verbal to behavioral. Women and minority groups (eg, race/ethnicity, age, gender, sexual orientation) are often marginalized during medical training and subsequent clinical practice. These contribute to the development of psychologically unsafe working environments and widespread physician burnout. Physicians experiencing burnout who work in unsafe psychological environments impact the safety and quality of patient care. In turn, these conditions impose high costs on the health care system and organizations. Microaggressions and psychological unsafe work environments are intricately related and mutually enhanced. Therefore, addressing both simultaneously is a good business practice and a responsibility for any health care organization. Additionally, addressing them can reduce physician burnout, decrease physician turnover, and improve the quality of patient care. To counter microaggression and psychological unsafe, it takes conviction, initiative, and sustainable efforts from individuals, bystanders, organizations, and government agencies.

Using Non-Invasive Respiratory Monitoring for COVID-19 Pulmonary Embolism Diagnosis.

With the high incidence rate of pulmonary embolism (PE) and pneumonia reported in hospitalized patients with COVID-19, the ability to determine the dominant etiology for severe respiratory distress quickly and accurately is crucial to a patient's well-being. Traditionally, D-dimer blood tests and diagnostic imaging studies would be utilized to determine the presence of a PE or a venous thromboembolism. However, COVID-19 places patients in a prothrombotic state and performing diagnostic imaging studies on all patients with COVID-19 would be impractical, making the need for a simple and reliable method to determine the likelihood of PE or venous thromboembolism a priority for emergency departments. The authors believe the use of non-invasive respiratory monitoring technology to assess lung function in hospitalized patients with COVID-19 can aid in discerning the dominant hypoxia etiology and tailoring of their treatment. Here, the authors outline a case and method of using non-invasive respiratory monitoring of lung function in the successful diagnosis of a PE in a 62-year-old patient with COVID-19.

Delayed Onset of Motor Blockade After Liposomal Bupivacaine Use for a Perioperative Popliteal Nerve Block: A Case Report.

We present a case of a 60-year-old male who has undergone Achilles' tendon repair with amnion augmentation on the right side. Before the surgery, liposomal bupivacaine was requested by the patient, and this was used to block the popliteal and adductor canal nerves for intraoperative anesthetic and postoperative pain control. The patient understood the benefits and risks of the regional nerve block with this medication and its off-label use. After the surgery, the patient underwent an irregular course of anesthetic, including delayed motor weakness, and became non-weight-bearing temporarily. The motor block was inconsistent and non-linear. Initially, the motor block completely resolved with a return to the sensation after three days. Then, on day four, a complete motor block developed, which resolved gradually over the next four days. After 10 days, the patient had full resolution of symptoms. He denies any pain since the surgery.

Implementation science for the adductor canal block: A new and adaptable methodology process.

BACKGROUND: Following the successful Perioperative Surgical Home (PSH) practice for total knee arthroplasty (TKA) at our institution, the need for continuous improvement was realized, including the deimplementation of antiquated PSH elements and introduction of new practices. AIM: To investigate the transition from femoral nerve blocks (FNB) to adductor canal nerve blocks (ACB) during TKA. METHODS: Our 13-month study from June 2016 to 2017 was divided into four periods: a three-month baseline (103 patients), a one-month pilot (47 patients), a three-month implementation and hardwiring period (100 patients), and a six-month evaluation period (185 patients). In total, 435 subjects were reviewed. Data within 30 postoperative days were extracted from electronic medical records, such as physical therapy results and administration of oral morphine equivalents (OME). RESULTS: Our institution reduced FNB application (64% to 3%) and increased ACB utilization (36% to 97%) at 10 mo. Patients in the ACB group were found to have increased ambulation on the day of surgery (4.1 vs 2.0 m) and lower incidence of falls (0 vs 1%) and buckling (5% vs 27%) compared with FNB patients (P < 0.05). While ACB patients (13.9) reported lower OME than FNB patients (15.9), the difference (P = 0.087) did not fall below our designated statistical threshold of P value < 0.05. CONCLUSION: By demonstrating closure of the "knowledge to action gap" within 6 mo, our institution's findings demonstrate evidence in the value of implementation science. Physician education, technical support, and performance monitoring were deemed key facilitators of our program's success. Expanded patient populations and additional orthopedic procedures are recommended for future study.

Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring.

Importance: Although the safety of labor epidural analgesia (LEA) for neonates has been well documented, the long-term health effects of LEA on offspring remain to be investigated. Objective: To assess the association between maternal LEA exposure and risk of autism spectrum disorders (ASDs) in offspring. Design, Setting, and Participants: Data for this retrospective longitudinal birth cohort study were derived from electronic medical records from a population-based clinical birth cohort. A total of 147 895 singleton children delivered vaginally between January 1, 2008, and December 31, 2015, in a single integrated health care system were included. Children were followed up from the age of 1 year until the first date of the following occurrences: clinical diagnosis of ASD, last date of health plan enrollment, death, or the study end date of December 31, 2018. Exposures: Use and duration of LEA. Main Outcomes and Measures: The main outcome was clinical diagnosis of ASD. Cox proportional hazards regression analysis was used to estimate the hazard ratio (HR) of ASD associated with LEA exposure. Results: Among the cohort of 147 895 singleton children (74 425 boys [50.3%]; mean [SD] gestational age at delivery, 38.9 [1.5] weeks), 109 719 (74.2%) were exposed to maternal LEA. Fever during labor was observed in 13 055 mothers (11.9%) in the LEA group and 510 of 38 176 mothers (1.3%) in the non-LEA group. Autism spectrum disorders were diagnosed in 2039 children (1.9%) in the LEA group and 485 children (1.3%) in the non-LEA group. After adjusting for potential confounders, including birth year, medical center, maternal age at delivery, parity, race/ethnicity, educational level, household income, history of comorbidity, diabetes during pregnancy, smoking during pregnancy, preeclampsia or eclampsia, prepregnancy body mass index, gestational weight gain, gestational age at delivery, and birth weight, the HR associated with LEA vs non-LEA exposure was 1.37 (95% CI, 1.23-1.53). Relative to the unexposed group, the adjusted HR associated with LEA exposure of less than 4 hours was 1.33 (95% CI, 1.17-1.53), with LEA exposure of 4 to 8 hours was 1.35 (95% CI, 1.20-1.53), and with LEA exposure of more than 8 hours was 1.46 (95% CI, 1.27-1.69). Within the LEA group, there was a significant trend of ASD risk associated with increasing duration of LEA exposure after adjusting for covariates (HR for linear trend, 1.05 [95% CI, 1.01-1.09] per 4 hours). Adding fever to the model did not change the HR estimate associated with LEA exposure (adjusted HR for LEA vs non-LEA, 1.37 [95% CI, 1.22-1.53]). Conclusions and Relevance: This study suggests that maternal LEA may be associated with increased ASD risk in children. The risk appears to not be directly associated with epidural-related maternal fever.

Respiratory Volume Monitoring in the Perioperative Setting Across Multiple Centers.

BACKGROUND: The prevalence of nuisance (technical) alarms is the leading cause of alarm fatigue resulting in decreased awareness and a reduction in effective care. The Joint Commission identified in their National Patient Safety goals alarm fatigue as a major safety issue. The introduction of noninvasive respiratory volume monitoring (RVM) has implications for effective perioperative respiratory status management. We evaluated this within the Kaiser Permanente health system. METHODS: This observational study was conducted at 4 hospitals in the Kaiser Permanente system. Standard data from RVM, pulse oximetry, and capnography were collected postoperatively in the post-anesthesia care unit (PACU) and/or on the general hospital floor. Device-specific alarm types, rates, and respective actions were recorded and analyzed by non-study staff. RESULTS: RVM was applied to 247 subjects (143 females, body mass index 32.3 ± 8.7 kg/m2, age 60.9 ± 13.9 y) providing 2,321 h. RVM alarms occurred 605 times (0.25 alarms/h); 64% were actionable and addressed, 17% were not addressed, 13% were self-resolved, and only 6% were nuisance. In a subgroup, RVM completed all 127 h of monitoring, whereas oximetry with capnography only completed 51 h with 12.9 alarms/h (73% nuisance). The overall RVM alarm rate was significantly lower than with either pulse oximeters or capnography monitors. We saw a nearly 1,000-fold reduction in nuisance alarms compared to capnography and a 20-50-fold reduction in nuisance alarms compared to pulse oximetry. CONCLUSIONS: Our study indicates that alarm fatigue due to nuisance alarms continues to be a clinical challenge in perioperative settings. Among the 3 common technologies for respiratory function monitoring, RVM had the lowest rate of overall technical alarms and the highest rate of compliance. Furthermore, with early interventions, none of the subjects monitored with RVM suffered any negative outcomes.

Is Anesthesia Technique Associated With a Higher Risk of Mortality or Complications Within 90 Days of Surgery for Geriatric Patients With Hip Fractures?

BACKGROUND: Postoperative mortality and complications after geriatric hip fracture surgery remain high despite efforts to improve perioperative care for these patients. One factor of particular interest is anesthetic technique, but prior studies on this are limited by sample selection, competing risks, and incomplete followup. QUESTIONS/PURPOSES: (1) Among older patients undergoing surgery for hip fracture, does 90-day mortality differ depending on the type of anesthesia received? (2) Do 90-day emergency department returns and hospital readmissions differ based on anesthetic technique after geriatric hip fracture repairs? (3) Do 90-day Agency for Healthcare Research and Quality (AHRQ) outcomes differ according to anesthetic techniques used during hip fracture surgery? METHODS: We conducted a retrospective study on geriatric patients (65 years or older) with hip fractures between 2009 and 2014 using the Kaiser Permanente Hip Fracture Registry. A total of 1995 (11%) of the surgically treated patients with hip fracture were excluded as a result of missing anesthesia information. The final study sample consisted of 16,695 patients. Of these, 2027 (12%) died and 98 (< 1%) terminated membership during followup, which were handled as competing events and censoring events, respectively. Ninety-day mortality, emergency department returns, hospital readmission, deep vein thrombosis (DVT) or pulmonary embolism (PE), myocardial infarction (MI), and pneumonia were evaluated using multivariable competing risk proportional subdistribution hazard regression according to type of anesthesia technique: general anesthesia, regional anesthesia, or conversion from regional to general. Of the 16,695 patients, 58% (N = 9629) received general anesthesia, 40% (N = 6597) received regional anesthesia, and 2.8% (N = 469) patients were converted from regional to general. RESULTS: Compared with regional anesthesia, patients treated with general anesthesia had a higher likelihood of overall 90-day mortality (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.11-1.35; p < 0.001); however, when stratified by before and after hospital discharge but within 90 days of surgery, this higher risk was only observed during the inpatient stay (HR, 3.83; 95% CI, 3.18-4.61; p < 0.001); no difference was observed after hospital discharge (HR, 1.04; 95% CI, 0.94-1.16; p = 0.408). Patients undergoing conversion from regional to general also had a higher overall mortality risk compared with those undergoing regional anesthesia (HR, 1.34; 95% CI 1.04-1.74; p = 0.026), but this risk was only observed during their inpatient stay (HR, 6.84; 95% CI, 4.21-11.11; p < 0.001) when stratifying by before and after hospital discharge. Patients undergoing general anesthesia had a higher risk for all-cause readmission when compared with regional anesthesia (HR, 1.09; 95% CI, 1.01-1.19; p = 0.026). No differences according to anesthesia type were observed for risk of 90-day AHRQ outcomes, including DVT/PE, MI, and pneumonia. CONCLUSIONS: We found the use of general anesthesia and conversion from regional to general anesthesia were associated with a higher risk of mortality during the in-hospital stay compared with regional anesthetic techniques, but this higher risk did not persist after hospital discharge. We also found general anesthesia to be associated with a higher risk of all-cause readmission compared with regional, but no other differences were observed in risk for complications. Our findings suggest regional anesthetic techniques may be preferred when possible in this patient population. LEVEL OF EVIDENCE: Level III, therapeutic study.

Impact of Anesthesia on Hospital Mortality and Morbidities in Geriatric Patients Following Emergency Hip Fracture Surgery.

OBJECTIVES: To determine the impact of anesthesia type on in-hospital mortality and morbidity for geriatric fragility hip fracture surgery. DESIGN: Retrospective cohort study. SETTING: Integrates health care delivery system across 38 facilities in the United States. PATIENTS/PARTICIPANTS: We identified 16,695 patients 65 years of age and older who underwent emergent hip fracture repairs between 2009 and 2014 through the Kaiser Permanente hip fracture registry and excluded pathologic or bilateral fractures. INTERVENTION: Hip fracture surgery with general or regional anesthesia. MAIN OUTCOMES MEASURES: Data on in-hospital mortality, time to death, discharge disposition, and length of stay (LOS) were analyzed among the following anesthesia types: general anesthesia (GA), regional anesthesia (RA), and intraoperative conversions from regional to general (Cv). RESULTS: Compared with RA, the hazard ratio for GA for in-hospital mortality was 1.38 and 2.23 for the Cv group; the time ratio for GA-associated time to death was 0.97 and 0.89 for the Cv group. The GA-associated time ratio for LOS before discharge was 1.01, and the hazard ratio for home discharge was 0.86, but no significance was found with the Cv group. CONCLUSIONS: RA may offer advantages over GA for fragility hip fracture surgeries when possible. In-hospital mortality, time to death, increased LOS, and discharge to an institute rather than home were all adversely influenced by GA. Furthermore, the previously understudied Cv group demonstrated adverse outcomes for in-hospital mortality and time to death. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Ambulatory Surgery Perioperative Surgical Home in Kaiser Permanente Settings: Practice and Outcomes.

BACKGROUND: The aim of this study is to describe the design, implementation, and associated outcome changes of a Perioperative Surgical Home (PSH) for patients undergoing ambulatory laparoscopic cholecystectomy in a Kaiser Permanente practice model. METHODS: A multidisciplinary planning committee of 15 individuals developed and implemented a new PSH program. A total of 878 subjects were included in the preimplementation period (T-fast), and 1082 patients were included in the postimplementation period (PSH) based on the date of their surgery. The primary goal of this report was to assess the changes in patient outcomes associated with this new PSH implementation on variables such as total length of stay and unplanned hospital admission (UHA). RESULTS: Patients assigned to the PSH model had a significantly shorter mean length of stay compared with patients in the T-fast group (162 ± 308 vs 369 ± 790 minutes, P = .00005). UHA was significantly higher in the T-fast group as compared with the PSH group (8.5% [95% CI 6.6-10.4] vs 1.7% [0.9-2.5], P < .00005). There was no difference in the 7 days readmission rates between patients managed in the T-fast track and the PSH track (5.4% [3.8-7.0] vs 5.0% [3.6-6.3], P = .066). CONCLUSIONS: Introduction of the PSH into a Kaiser Permanente model of care was associated with a simultaneous decrease of length of stay and UHA for laparoscopic cholecystectomy patients.

Practice and Outcomes of the Perioperative Surgical Home in a California Integrated Delivery System.

BACKGROUND: In this article, we report on the implementation and impact of a Perioperative Surgical Home (PSH) model for the total knee arthroplasty at an integrated delivery system (Kaiser Permanente). METHODS: A multidisciplinary committee developed and implemented a series of PSH protocols that included the entire continuum of care from the decision for surgery until 30 days after surgery. Five hundred forty-six subjects were included in the preimplementation phase (Fast Track [T-fast]), and 518 patients were included in the postimplementation phase (PSH). The primary end points of this report are hospital length of stay (LOS), postoperative skilled nursing facility (SNF) bypass rate, and 30-day readmission rate. We used a generalized linear model to assess the effect on LOS while adjusting for potential confounding variables. RESULTS: We found that patients assigned to the PSH pathway had a significantly shorter mean LOS compared with patients in the T-fast group (2.4 ± 2.1 days [confidence interval {CI}, 2.2-2.8] vs 3.4 ± 2.9 days [CI, 2.9-3.9]). The SNF bypass rate was significantly higher in the PSH group compared with the T-fast group (94% vs 80%, P = 0.00002, CI, -0.102 to -0.036). There was no difference in the 30 readmission rates between patients managed in the PSH track and the T-fast track (1.2% vs 0.98%). CONCLUSIONS: Introduction of the PSH into an integrated delivery system resulted in a simultaneous reduction of LOS and SNF admission for total knee arthroplasty patients.